ITV news reports coroner's warnings following death of Edward Cassin
Caron Heyes was interviewed by ITV news recently with the sisters of Eddie Cassin, a 67-year-old man with learning difficulties who died after being negligently fed jelly by nurses at Milton Keynes University Hospital, despite having known swallowing difficulties.
In partnership with Mencap, Caron represented Eddie's family pro bono at the recent inquest into his death.
At the inquest, Assistant Coroner Dr Sean Cummings delivered a neglect verdict. Because he was not adequately supervised by hospital staff, Eddie was left with food and medication in his mouth, which caused him to aspirate. Staff did not recognise this and the coroner concluded it exacerbated his already developing aspiration pneumonia that was contributed to by feeding him jelly.
The coroner concluded that had Eddie been treated for the developing aspiration pneumonia, he would likely not have died at the time he did.
An independent review conducted in November 2024 into policy and practice around the care of inpatients with vulnerabilities relating to swallowing at Milton Keynes University Hospital found that there have been four deaths in three years at the hospital related to feeding and a fifth case where the patient survived. At least 50% of these involve vulnerable patients.
Dr Cummings followed up his conclusions with a Regulation 28 Report, the sternest warning a coroner can issue, because he believed further lives were at risk at the hospital unless change is rapidly implemented.
Dr Cummings' warning was that:
"The Speech and Language Therapists (SALT) and Dietetic Service had well developed, comprehensive guidelines for investigating and managing patients prone to aspiration.
"Those guidelines were disseminated through the wards at Milton Keynes University Hospital and nursing and other staff were appraised of them or at least, should have been.
"I was disturbed to discover though that there was a lack of understanding of some of those policies and procedures some 22 months or so after the death. The SALT and Dietetic services are provided by the Central and North West London NHS Trust into the Milton Keynes University Hospital NHS Foundation Trust. It appeared to me that both Trusts were working to a degree in a siloed manner and that closer co-operation and sharing of clinical responsibility would benefit patients in a similar position in the future."
On ITV news, Caron said that systemic failings within hospital settings were an ongoing and serious cause for concern, meaning people were dying because information is not properly shared among staff.
Watch the full ITV interview here
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